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Women's Health Highlights: Recent Findings

Program Brief

This program brief summarizes findings from a cross-section of AHRQ-supported research projects focusing on women's health topics published January 2006 through December 2009.

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Introduction
Cardiovascular Disease
Cancer Screening and Treatment
Reproductive Health
Chronic Illness and Care
Health Impact of Violence Against Women
Health Care Costs and Access to Care
Health Care Quality and Safety
Women and Medications
Data Sources for Gender Research

Introduction

At the beginning of the 20th century, U.S. women were most likely to die from infectious diseases and complications of pregnancy and childbirth. In 2006, the chronic conditions of heart disease, cancer, and stroke accounted for 55 percent of American women's deaths, and they continue to be the leading causes of death for both women and men.

Women have a longer life expectancy than men, but they do not necessarily live those extra years in good physical and mental health. On average, women experience 3.1 years of reduced physical functioning at the end of life, and in 2008, 14 percent of women aged 18 and older who were surveyed said they were in fair or poor health.

The Agency for Healthcare Research and Quality (AHRQ) supports research on all aspects of health care provided to women, including:

Enhancing the response of the health system to women's needs.
Understanding differences between the health care needs of women and men.
Understanding and eliminating disparities in health care.
Empowering women to make well-informed health care decisions.

This summary presents findings from a cross-section of AHRQ-supported research projects on women's health published January 2006 through December 2009. An asterisk (*) at the end of a summary indicates that reprints of an intramural study or copies of other publications are available from the AHRQ Clearinghouse.

Go to the last page of this brief to find out how you can get more detailed information on AHRQ's research programs and funding opportunities.

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Cardiovascular Disease

Heart disease is the number one killer of women in the United States. More than one-fourth of all deaths among U.S. women in 2006 were due to heart disease, which usually occurs about 10 years later in life in women than in men. Heart disease mortality differs substantially among women of different races, and almost two-thirds of women who die suddenly of coronary heart disease have no previous symptoms.

Association found between cardiac illness and prior use of a certain type of breast cancer drug.
According to this 16-year study of nearly 20,000 women with breast cancer, those who received chemotherapy that included anthracycline had a higher incidence of congestive heart failure, cardiomyopathy, and dysrhythmia than women who received other kinds of chemotherapy or no chemotherapy. For example, the probability of experiencing congestive heart failure in year 10 was 32 percent for women who received anthracycline, compared with 26 percent for women who received other types of chemotherapy and 27 percent for those who received no chemotherapy. Du, Siz, Liu, et al., Cancer 115(22):5296-5308, 2009 (AHRQ grant HS16743).
Women are more likely than men to experience delays in emergency care for cardiac symptoms.
Researchers examined time-to-treatment for 5,887 individuals with suspected cardiac symptoms who made a call to 911 in 2004. They found that on average, women arrived at the hospital 2.3 minutes slower than men. Factors increasing the likelihood of delay included evening rush hour travel, bypassing a local hospital, and living in a densely populated neighborhood. Even after adjustments were made for these factors, women were significantly more likely than men to be delayed. Concannon, Griffith, Kent, et al., Circ Cardiovasc Qual Outcomes 2:9-15, 2009 (AHRQ grants HS10282, T32 HS00060).
Postmenopausal women with metabolic syndrome are at increased risk for a cardiovascular event.
Researchers used data on 372 postmenopausal women to investigate the effects of using two competing clinical definitions of metabolic syndrome on their usefulness in identifying women at high risk of future heart attacks or stroke. Metabolic syndrome—a combination of high blood pressure, elevated blood glucose, abnormal lipid levels, and increased waist size—is known to be associated with elevated risk for heart attack and stroke. Overall, women who met at least one of the definitions for metabolic syndrome were significantly more likely to experience a cardiovascular event than those who did not, and there was no difference between the two definitions in their predictive ability. Brown, Vaidya, Rogers, et al., J Womens Health 17(5):841-847, 2008 (AHRQ grant HS13852).
Aspirin therapy to prevent heart attack may have different benefits and harms in men and women.
The U.S. Preventive Services Task Force reviewed new evidence from NIH's Women's Health Study and other recent research and found good evidence that aspirin decreases first heart attacks in men and first strokes in women. The Task Force has issued a recommendation that women between the ages of 55 and 70 should use aspirin to reduce their risk for ischemic stroke when the benefits outweigh the harms for potential gastrointestinal bleeding. The recommendation and other materials are available at http://www.USPreventiveServicesTaskForce.org/uspstf/uspsasmi.htm. U.S. Preventive Services Task Force, Ann Intern Med 150(6):396-404, 2009 (AHRQ supports the Task Force). See also Optowsky, McWilliams, and Cannon, J Gen Intern Med 22:55-61, 2007 (AHRQ grant T32 HS00020).
Women are more likely than men to be hospitalized for unexplained chest pain.
Data show that in 2006, there were 477,000 admissions of women to U.S. hospitals for unspecified chest pain—feeling of pressure, burning, or numbness—compared with 379,000 admissions for men. Although it is not clear why women receive this diagnosis more than men, there is some evidence that heart disease develops differently in women and men, and their symptoms may differ. Go to HCUP Facts and Figures 2006, online at http://www.hcup-us.ahrq.gov/reports/factsandfigures.jsp (Intramural).
Female and black stroke patients are less likely than others to receive preventive care for subsequent strokes.
A third of stroke survivors suffer another stroke within 5 years, and there are several therapies to prevent further strokes in these patients. According to this study of 501 patients hospitalized for stroke, 66 percent of women and 77 percent of blacks received incomplete inpatient evaluations, compared with 54 percent of men and 54 percent of whites. Also, women were more likely than men to receive incomplete discharge regimens (anticoagulants and other stroke prevention medications and outpatient followup). Tuhrim, Cooperman, Rojas, et al., J Stroke Cerebrovasc Dis 17(4):226-234, 2008 (AHRQ grant HS10859).
Process-of-care variables may explain some of the male-female differences in cardiovascular disease outcomes.
Researchers analyzed seven cardiovascular disease (CVD) quality of care indicators in a national sample of managed care plans and found inadequate lipid control in both men and women, with a lower rate of control in women. Also, women with diabetes were 19 percent less likely than men to have their LDL cholesterol controlled; women with a history of CVD were 28 percent less likely than men to have their LDL cholesterol controlled. More women than men had their blood pressure controlled, although the difference was small (2 percent). Chou, Scholle, Weisman, et al., Women's Health Issues 17:120-130, 2007 (AHRQ contract 290-04-0018).
Commercial health plans show disparities between women and men in cardiovascular care.
Researchers evaluated plan-level performance of seven quality of care measures for CVD and found that over half of the plans showed a disparity of 5 percent or more in favor of men for cholesterol control measures among people with diabetes, a recent CVD procedure, or heart attack. The greatest disparity (9.3 percent in favor of men) was among those with recent acute cardiac events; none of the plans showed disparities in favor of women. Disparities between women and men were even greater among Medicare managed care plans. Chou, Wong, Weisman, et al., Women's Health Issues 17:139-149, 2007 (AHRQ contract 290-04-0018). Go to also Bird, Fremont, Bierman, et al., Women's Health Issues 17:131-138, 2007 (AHRQ contract 290-00-0012).
Women continue to fare worse than men in treatment for heart attack and congestive heart failure.
According to this study of gender disparities among adults age 65 and older, women with acute myocardial infarction (AMI) or congestive heart failure (CHF) do not receive the same care as men. Also, women or men who have other medical conditions associated with AMI or CHF—such as diabetes, hypertension, or end-stage renal disease—do not receive better quality of cardiovascular care than those who have only the heart conditions. Correa-de-Araujo, Stevens, Moy, et al., Women's Health Issues 16(2):44-55, 2006 (AHRQ Publication No. 06-R042)* (Intramural).
Immunosuppression related to transfusion may explain women's increased risk of dying after CABG surgery.
A study of more than 9,000 Michigan Medicare patients found that women undergoing coronary artery bypass graft (CABG) surgery were 3.4 times as likely as men to have received blood transfusions and generally received more units of blood, after accounting for age, coexisting conditions, and other factors. Patients who received a transfusion were more than three times as likely to develop an infection as those who did not, and they were 5.6 times as likely to die within 100 days after surgery. The presence of foreign leukocytes in donor blood may suppress the immune system of the recipient and thus increase the risk of postoperative infection, note the researchers. Rogers, Blumberg, Saint, et al., Am Heart J 152:1028-1034, 2006 (AHRQ grant HS11540).

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Cancer Screening and Treatment

Breast cancer continues to be the most commonly diagnosed cancer among women in the United Sates. In 2008, an estimated 182,400 U.S. women were newly diagnosed with breast cancer, and more than 40,000 women died from the disease.

The good news is that breast cancer deaths have declined recently among white women in this country; the bad news is that over the same period, survival has decreased among black women. The 5-year breast cancer survival rate is 69 percent for black women, compared with 85 percent for white women.

In 2008, there were an estimated 11,000 newly diagnosed cases of invasive cervical cancer in U.S. women, and about 3,900 women died from the disease. Cervical cancer occurs most often among minority women, particularly Asian-American (Vietnamese and Korean), Alaska Native, and Hispanic women. Although deaths from cervical cancer have declined substantially over the past 30 years, the cervical cancer death rate for black women continues to be more than twice that of white women.

Breast Cancer

Booklet provides helpful information about breast biopsy.
This guide for women with breast cancer discusses the different kinds of breast biopsies, including their accuracy and side effects. It can help women who need biopsies talk with their doctors and nurses about the procedure and what to expect. Having a Breast Biopsy: A Guide for Women and Their Families (AHRQ Publication No. 10-EHC007-A).* Go to also Core-Needle Biopsy for Breast Abnormalities: Clinician Guide (AHRQ Publication No. 10-EHC-007-3)* (AHRQ contract 290-02-0019).
Guide for women discusses two drugs used to lower the risk of breast cancer.
Two drugs—tamoxifen and raloxifene—have been approved for the prevention of primary (first occurrence) breast cancer in women who have a higher than average risk of breast cancer. This guide provides information about the drugs' benefits, side effects, and cost, and can help women talk with their doctors to decide whether one of these drugs would be right for them. Reducing the Risk of Breast Cancer with Medicine: A Guide for Women (AHRQ Publication No. 09(10)EHC028-A).* Go to also Medications to Reduce the Risk of Primary Breast Cancer in Women: Clinician Guide (AHRQ Publication No. 09(10)-EHC028-3)* (AHRQ contract 290-2007-10057-1).
Nonsurgical method for diagnosing breast cancer found to be safe and effective.
This AHRQ report compares the safety and effectiveness of traditional surgical biopsies with various types of "core needle biopsy" for diagnosing breast cancer. Based on a review of scientific evidence, it shows that certain core needle biopsies could distinguish between malignant and benign lesions approximately as accurately as open surgical biopsy, commonly considered to be the gold standard for evaluating suspicious lesions. The report provides important information to help physicians and patients work together to make the best possible diagnostic choice for each patient. Comparative Effectiveness of Core Needle and Open Surgical Biopsy for the Diagnosis of Breast Lesions, Comparative Effectiveness Review No. 19, Executive Summary (AHRQ Publication No. 10-EHC007-1)* (Contract 290-02-0019).
Less than 15 percent of radiologists say they definitely would tell a patient about an error in mammogram interpretation.
A survey of 243 radiologists at seven geographically dispersed breast cancer surveillance sites found that 9 percent of those surveyed definitely would not disclose an error in mammogram interpretation; 51 percent would disclose the error only if specifically asked by the patient; 26 percent said they probably would disclose the error; and just 14 percent said they definitely would disclose the error. Neither concern about the effects that malpractice is having on the practice of radiology nor having been sued previously were associated with disclosure willingness or disclosure content. Gallagher, Cook, Brenner, et al., Radiology 253(2):443-452, 2009 (AHRQ grant HS10591).
Automated telephone reminders lead to increased use of mammography.
Researchers tested the effectiveness of automated telephone reminders (ATRs), enhanced reminder letters, and standard letters on the likelihood of repeat mammograms in 3,547 women who were randomly assigned to one of the three groups. The ATRs were found to be the least costly but most effective (76 percent) intervention for prompting repeat mammograms compared with the enhanced (72 percent) and standard (74 percent) reminder letters. Overall, 74 percent of women had a repeat mammogram within 10-14 months compared with 57 percent before the reminders. DeFrank, Rimer, Gierisch, et al., Am J Prevent Med 36(6):459-467, 2009 (AHRQ grant T32 HS00079).
In St. Louis, black women are more likely than white women to receive mammograms.
St. Louis, MO, is known to have high rates of breast cancer diagnosed at a late-stage, and researchers have been looking at ways to increase mammography use in late-stage diagnosis areas. From March 2004 to June 2006, researchers conducted a survey of women (429 black, 556 white) older than age 40 living in the St. Louis area. Unexpectedly, more black women (75 percent) than white women (68 percent) reported that they had received mammograms. The researchers note that such geographic clustering of late-stage breast cancer diagnosis can be useful in targeting interventions to increase mammography use. Lian, Jeffe, and Schootman, J Urban Health 85(5):677-692, 2008 (AHRQ grant HS14095).
Radiologists' perception of malpractice risk appears to be higher than the actual number of lawsuits.
Researchers mailed a survey in 2002 and again in 2006 to radiologists in three States—Washington, Colorado, and New Hampshire—to determine their perceived risk of facing a lawsuit related to mammogram interpretation. They found that the radiologist's perceived risk of being sued was significantly higher than the actual number of reported malpractice cases involving breast imaging. Radiologists who spent more time on breast imaging or interpreting a higher volume of mammograms did not have a significantly higher perceived risk of a lawsuit. Those who felt more at risk were more likely to have had a malpractice claim in the past or know of other radiologists who had been sued. Dick, Gallagher, Brenner, et al., Am J Roentgenol 192(2):327-333, 2009 (AHRQ grant HS10591).
Study finds no correlation between abnormal mammogram interpretation and radiologists' job satisfaction.
In this study, 131 radiologists were surveyed about their clinical practices and attitudes related to screening mammography. Performance data were used to determine the odds of an abnormal mammogram interpretation. More than half of the radiologists said they enjoyed interpreting screening mammograms; most in this group were female, older, and working part time; affiliated with academic medical centers; and/or on an annual salary. Those who did not enjoy the work reported it as being tedious. There were no significant differences in mammogram interpretation and cancer detection between those who did and did not enjoy their work. Geller, Bowles, Sohng, et al., Am J Roentgenol 192(2):361-369, 2009 (AHRQ grant HS10591).
Lack of knowledge and mistrust may partly explain women's underuse of adjuvant therapy for breast cancer.
Adjuvant therapies (chemotherapy, hormone therapy, and radiotherapy) following breast cancer surgery have been proven effective in women with early-stage breast cancer, yet 32 of 258 women in this study who should have received adjuvant therapy did not get it. According to practice guidelines, 64 of the women should have received chemotherapy, 150 should have received hormone therapy, and 174 should have received radiotherapy. The principal factors associated with lack of adjuvant treatment were age older than 70, coexisting illnesses, and mistrust in the medical delivery system. The researchers call for better education of women regarding the benefits and risks of treatment, as well as straightforward discussion about issues of trust. Bickell, Weidmann, Fei, et al., J Clin Oncol 27(31):5160-5167, 2009. Go to also Bickell, LePar, Wang, and Leventhal, J Clin Oncol 25(18):2516-2521, 2007 (AHRQ grant HS10859; Anderson and Carlson, J Natl Compr Canc Netw 5(3):349-356, 2007 (AHRQ grant HS15756); and Fryback, Stout, Rosenberg, et al., J Natl Cancer Inst Monographs 36:37-47, 2006 (AHRQ grant T32 HS00083).
Tracking system helps to ensure women with breast cancer see oncologists and receive followup care.
Some women diagnosed with breast cancer, especially blacks and Latinos, do not follow through with their referrals to an oncologist. To address this problem, researchers developed a tracking system to facilitate followup with breast cancer patients. They compared the treatment of 639 women with early stage breast cancer who were seen at six New York City hospitals between January 1999 and December 2000 with 300 women who were seen between September 2004 and March 2006, after the tracking system began. Rates of oncology consultations, chemotherapy, and hormone therapy were higher for all women once the system was in place, and the racial disparities in use of care that had existed were eliminated. Bickell, Shastri, Fei, et al., J Natl Cancer Inst 100(23):1717-1723, 2008 (AHRQ grant HS10859).
Study finds that three drugs effectively reduce risk of breast cancer but may cause other problems.
Three drugs—tamoxifen, raloxifene, and tibolone—significantly reduce invasive breast cancer in middle-aged and older women who are at risk but have not previously had breast cancer. However, each of the three drugs has its own side effects and risks, and these must be balanced against the benefits for an individual patient. For example, tamoxifen carries an increased risk for endometrial cancer and blood clots and has side effects such as flushing, night sweats, and vaginal dryness. Raloxifene also carries a risk for blood clots and has side effects such as flushing and leg cramps. Tibolone carries an increased risk of stroke and has side effects that include vaginal bleeding. Comparative Effectiveness of Medications to Reduce Risk of Primary Breast Cancer in Women, Executive Summary No. 17 (AHRQ Publication No. 09-EHC028-1)* (AHRQ contract 290-2007-10057-1).
Poverty may explain racial disparities in receipt of chemotherapy for breast cancer in older women.
According to this study of nearly 14,500 older women with stage II or IIIA breast cancer with positive lymph nodes, black women were less likely than white women to receive chemotherapy within 6 months of diagnosis (56 percent vs. 66 percent, respectively). When the results were adjusted to include socioeconomic status for women aged 65 to 69, poverty appeared to be at the root of the disparity. Despite Medicare coverage, out-of-pocket costs—including copayments, transportation, and so on—may be overwhelming for women in the lowest income groups. Bhargava and Du, Cancer 115(13):2999-3008, 2009 (AHRQ grant HS16743).
Online support groups seem to benefit women with metastatic breast cancer.
A group of 20 women (all were white) with metastatic breast cancer were assigned to one of three online support groups. The women received a monthly e-mail questionnaire and after at least 4 months in the support group, each woman was interviewed for 30 to 90 minutes. Six helpful factors identified in an earlier study were found to be present in these groups: group cohesiveness, universality, information exchange, instillation of hope, catharsis, and altruism. Vilhauer, Women Health 49:381-404, 2009 (AHRQ grant HS10565).
Behavioral health carve-outs limit access to mental health services for women with breast cancer.
Up to 40 percent of women with breast cancer suffer significant psychological distress, but only about 30 percent of them receive treatment for it, according to this study. Researchers analyzed insurance claims, enrollment data, and insurance benefit design data from 1998-2002 on women 63 years of age or younger with newly diagnosed breast cancer. They found that women enrolled in insurance plans with behavioral health carve-outs were 32 percent less likely to receive mental health services compared with women in plans that had integrated behavioral health services. Azzone, Frank, Pakes, et al., J Clin Oncol 27(5):706-712, 2009 (AHRQ grant HS10803)
Journal supplement focuses on guidelines for international implementation of breast health and breast cancer control initiatives.
This journal supplement presents a series of 15 articles authored by a group of breast cancer experts and advocates and presented at the Global Summit on International Breast Health Implementation held in Budapest, Hungary, in October 2007. The articles focus on guideline implementation for early detection, diagnosis, and treatment; breast cancer prevention; chemotherapy; and other breast health topics. Cancer 113, Supplement 8, 2008 (AHRQ grant HS17218).
Several factors affect the accuracy of mammogram interpretation.
Researchers examined how differences among mammography facilities affect the results of mammogram interpretation. They found that the most accurate facilities offered screening but not diagnostic mammograms, had a breast imaging specialist on staff, and conducted audits of radiologists' performance two or more times per year. Their findings are based on a review of 5 years of mammogram data and results of surveys received from 43 facilities and their 128 radiologists in the Pacific Northwest, New Hampshire, and Colorado. Taplin, Abraham, Barlow, et al., J Natl Cancer Inst 100(12):876-887, 2008 (AHRQ grant HS10591). See also Miglioretti, Smith-Bindman, Abraham, et al., J Natl Cancer Inst 99(24):1854-1863, 2007 (AHRQ grant HS10591).
Lesions overlooked on mammograms represent missed opportunities for early diagnosis.
Among women with breast cancers that are diagnosed between routine screening mammograms, 10 to 20 percent have lesions that were visible but overlooked at their previous exam, and a similar percentage have lesions that were misinterpreted at the previous exam. In both cases, the opportunities for early diagnosis and intervention were missed. These authors discuss the pros and cons of double or even quadruple reading of mammograms and computer-aided detection as a second digital "reader" of mammograms. Elmore and Brenner, J Natl Cancer Inst 99(15):1141-1143, 2007 (AHRQ grant HS10591).
Requirement for cost-sharing reduces use of mammography among some groups of women.
Researchers examined data on mammography use and cost-sharing from 2002 to 2004 for more than 365,000 women covered by Medicare. Of the 174 Medicare health plans studied, just 3 required copayments of $10 or more or coinsurance of more than 20 percent in 2001; by 2004, 21 plans required cost-sharing of one form or another. The increase in coinsurance requirements correlated with a decrease in screening mammograms. Less than 70 percent of women in cost-sharing plans were screened, compared with nearly 80 percent of fully covered women. Although every demographic group was affected, black women and women with lower incomes and educations levels often were covered by plans that required cost-sharing. Trivedi, Rakowski, and Ayanian, N Engl J Med 358(4):375-383, 2008 (AHRQ grant T32 HS00020).
Breast desmoid tumors are rare and often mistaken for cancer.
A review over 25 years (1982-2006) at one institution identified 32 patients with pathologically confirmed breast desmoids. Their median age was 45; eight patients had a prior history of breast cancer, and 14 had undergone breast surgery, with desmoids diagnosed an average of 24 months postoperatively. All patients presented with physical findings; MRI was more accurate in visualizing the mass than mammography or ultrasound. All patients had their tumors surgically removed, and eight patients had recurring tumors at a median of 15 months. The researchers recommend that clinical judgment be used before extensive and potentially deforming breast resections are performed. Neuman, Brogi, Ebrahim, et al., Ann Surg Oncol 15(1):274-280, 2008 (AHRQ grant T32 HS00066).
More attention is needed to quality of life for breast cancer survivors.
Researchers examined quality of life among women with (114 women) and without (2,527 women) breast cancer. Women with breast cancer reported lower scores on physical function, general health, vitality, and social function compared with women who did not have breast cancer. There was no difference in mental health scores between the two groups of women. Trentham-Dietz, Sprague, Klein, et al., Breast Cancer Res 109:379-387, 2008 (AHRQ grant HS06941).
Study underway to develop computer-based tools to improve use of genetic breast cancer tests.
AHRQ has funded a new project to develop, implement, and evaluate four computer-based decision-support tools that will help clinicians and patients better use genetic tests to identify, evaluate, and treat breast cancer. The first pair of tools will assess whether a woman with a family history of cancer should be tested for BRCA1 and BRCA2 gene mutations. The second pair of tools, for women already diagnosed with breast cancer, will help determine which patients are suitable for a gene expression profiling test that can evaluate the risk of cancer recurrence and whether they should have chemotherapy. More information is available online at http://effectivehealthcare.ahrq.gov (AHRQ contract 290-200-50036I).
Report discusses impact of several gene expression profiling tests for breast cancer patients.
Breast cancer treatment today often involves a multi-modality approach, including surgery, radiation therapy, endocrine therapy, and/or chemotherapy. Gene expression profiling has been proposed as an approach to assess women's risk of distant disease recurrence. This report discusses the available evidence on three breast cancer gene expression assays: the Oncotype DX™ Breast Cancer Assay, the MammaPrint® Test, and the Breast Cancer Profiling Test. Tests that improve such estimates of risk potentially can affect clinical outcome in breast cancer patients by either avoiding unnecessary chemotherapy or employing it where it otherwise might not have been used. Impact of Gene Expression Profiling Tests on Breast Cancer Outcomes, Evidence Report/Technology Assessment No. 160 (AHRQ Publication No. 08-E002)* (AHRQ contract 290-02-0018).
Noninvasive tests may miss breast cancer.
This report indicates that four common noninvasive tests for breast cancer are not accurate enough to replace biopsies for women who receive abnormal findings from mammography or a clinical breast exam. Researchers found that each of the four tests—magnetic resonance imaging (MRI), ultrasonography (ultrasound), positron emission tomography scanning (PET scan), and scintimammography (nuclear medicine scan)—would miss a significant number of cases of cancer, compared with immediate biopsy, in women at high enough risk to warrant evaluation for breast cancer. Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities, Executive Summary No. 2 (AHRQ Publication No. 06-EHC005-1)* and online at http://effectivehealthcare.ahrq.gov.
Radiation therapy for a primary cancer that develops in a second breast may offer a survival benefit.
Radiation therapy following breast-conserving surgery (BCS) for a primary breast cancer reduces the risk of recurrence, but it has only a small overall survival benefit. However, omission of radiation therapy following BCS for a primary cancer that later develops in a second breast appears to double the risk of dying, according to this study. Researchers compared mortality rates of women aged 40 to 69 who did not receive radiation therapy following BCS for the second breast (43 percent of women) with those who did. Women who did not receive radiation had slightly more than twice the risk of dying from breast cancer and 1.7 times the risk of dying from all causes as women who received radiation. Schootman, Jeffe, Gillanders, et al., Breast Cancer Res Treat 103:77-83, 2007 (AHRQ grant HS14095). Go to also Du, Fan, and Meyer, Am J Clin Oncol 31(2):125-132, 2008 (AHRQ grant HS16743); and Schootman, Fuortes, and Aft, Breast Cancer Res Treat 99:91-95, 2006 (AHRQ grant HS14095).
Booklet helps women assess their treatment options for early-stage breast cancer.
Women newly diagnosed with early-stage breast cancer usually can choose between mastectomy and breast-conserving surgery (lumpectomy) followed by radiation. Research has shown that long-term outcomes are similar for both treatments. This booklet provides information to help women work with their providers to choose which type of surgery they will have and, if they choose mastectomy, whether they want to have reconstructive surgery. The booklet was developed collaboratively by the National Cancer Institute and AHRQ. Surgery Choices for Women with Early-Stage Breast Cancer (AHRQ Publication No. PHS 04-M053, English; AHRQ 05-0031, Spanish)* (Intramural).
Race, age, and other factors affect degree of pain among women with breast cancer.
Researchers studied 1,124 women with stage IV breast cancer over the course of a year and found that minority women who had advanced breast cancer suffered more pain than white women. In addition, women who were inactive and younger women also reported more severe pain. Castel, Saville, DePuy, et al., Cancer 112(1):162-170, 2008 (AHRQ grant T32 HS00032).
Death and complications following breast cancer surgery are rare.
The most common complication of breast cancer surgery is wound infection, which is twice as common after mastectomy as lumpectomy and lymph node dissection, according to this study. Factors that may contribute to the higher rate of wound infection following mastectomy include extensive tissue dissection, drain placement, formation of pockets of fluid, and longer operation time, as well as a woman's overall health status. Researchers analyzed data on 1,660 women (mean age 56) who underwent mastectomy and 1,447 women who underwent breast conserving surgery at 14 university and 4 community medical centers. There were few cardiac or pulmonary complications in the mastectomy group and none in the lumpectomy group; central nervous system problems were rare in both groups. El-Tamer, Ward, Schifftner, et al., Ann Surg 245(5):665-671, 2007 (AHRQ grant HS11913).
Breast screening is less common in counties that have many uninsured women.
Researchers used data from two large surveillance systems to determine whether screening for breast cancer varied by the proportion of uninsured women in the community. The data showed that as the rate of uninsurance in a community increased by 5 percent, women were 5 percent less likely to receive either clinical breast exams or mammograms. Breast cancer screening declined significantly for women earning $25,000 to $75,000 who lived in counties with high rates of uninsurance. On the other hand, black women and Hispanic women had higher screening rates than white women when they lived in communities with low rates of uninsurance. Schootman, Walker, Jeffe, et al., Am J Prevent Med 33(5):379-386, 2007 (AHRQ grant HS14095).
Women aged 40 to 49 were responsive to changes in mammography recommendations.
According to interviews with 1,451 women who received screening mammograms at one of five hospital-based clinics between October 1996 and January 1998, opinions about mammography have changed among women aged 40 to 49. Prior to the issuance of recommendations by the American Cancer Society and the National Cancer Institute that women aged 40 to 49 should receive screening mammograms every 1 or 2 years, only 49 percent of women in this age group endorsed annual screening. After the new recommendations were issued, 64 percent of women in this age group endorsed annual screening. Calvocoressi, Sun, Kasl, et al., Cancer 120(3):473-480, 2008 (AHRQ grant HS11603).
Immediate reading of mammograms and followup on false-positive results reduce anxiety among women.
A group of women aged 40 and older participated in this study at seven sites in the Boston area between February 1999 and January 2001. Radiologists read the mammograms of 564 women immediately, while the films of 576 women were read in batches at a later time. Although there were more false-positives in the immediate-reading group, that strategy provided quick resolution of false-positives and led to significantly lower anxiety among those women. Immediate reading of mammograms increased costs to health plans by 10 percent because of reduced efficiency and the need for extra films. However, 12-month costs did not differ significantly between the two groups. Stewart, Neumann, Fletcher, and Barton, Health Serv Res 42(4):1464-1482, 2007 (AHRQ Publication No. 07-R067)* (Intramural).
Depression hinders recovery of older breast cancer patients.
Researchers examined data on 187 women aged 60 years and older, including the presence of depressive symptoms 2 months after breast cancer diagnosis. They also examined sociodemographic factors, type of breast cancer treatment, and shoulder range of motion at 12 months after diagnosis. Results showed that each unit increase in depressive symptoms was associated with an 8 percent decreased odds of having full range of shoulder motion a year after diagnosis. Caban, Freeman, Zhang, et al., Clin Rehabil 20:513-522, 2006 (AHRQ grant HS11618).
Poor communication of mammogram results may explain disparities in breast cancer diagnosis and outcomes.
Researchers surveyed 411 black and 734 white women who had screening mammograms at five hospital-based facilities in Connecticut between 1996 and 1998 and found no difference between the two groups of women in the proportion of abnormal screening mammograms. However, communication of mammogram results was problematic for 14.5 percent of the women; 12.5 percent had not received their results, and 2 percent had received their results but their self-report differed from the radiology record. Inadequate communication of mammogram results was nearly twice as common among black women as among white women. Jones, Reams, Calvocoressi, et al., Am J Public Health 97(3):531-538, 2007 (AHRQ grant HS11603). See also Dailey, Kasl, Holford, and Jones, Am J Epidemiol 165(11):1287-1295, 2007 (AHRQ grant HS15686).
Physician communication style may depend on characteristics of breast cancer patients.
According to this study, oncologists tend to communicate differently with women newly diagnosed with breast cancer, depending on their age, race, education, and income. A series of videotaped visits between 58 oncologists with 405 women revealed that the physicians spent more time engaged in building relationships with white women than with women of other races; the same was true of visits with more educated and affluent patients compared with less advantaged patients. The women who asked more questions tended to be younger, white, better educated (beyond high school), and more affluent than other patients. Siminoff, Graham, and Gordon, Patient Educ Counsel 62:355-360, 2006 (AHRQ grant HS08516).
Breast and gynecologic cancers account for one-fourth of all cancer hospitalizations among women.
This publication summarizes findings on hospital use, outpatient surgery use, hospital charges, and changing practice patterns for the care of breast and gynecologic cancers in U.S. women. The information is based on inpatient hospital discharge data and outpatient ambulatory surgery data from AHRQ's Healthcare Cost and Utilization Project (HCUP) and covers the period 1993-2003. Hospital and Ambulatory Surgery Care for Women's Cancers, HCUP Highlights No. 2 (AHRQ Publication No. 06-0038).*
Task Force revises recommendations for mammography.
The U.S. Preventive Services Task Force updated its recommendation by calling for screening mammography, with or without clinical breast exam, every 1 to 2 years for women 40 and over. The recommendation acknowledges some risks associated with mammography, which will lessen as women age. The strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50 to 69. The recommendation and materials for clinicians and patients are available at http://www.USPreventiveServicesTaskForce.org/uspstf/uspsbrca.htm (Intramural).

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